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Based on hospital policy and procedure reviews, medical record reviews, observational tours, staff interviews, the hospital leadership failed to provide oversight and to have systems in place to ensure constant observation of a behavioral health patient and failed to provide a safe physical environment according to the precaution level of a behavioral health patient.

The findings include:

1. The hospital staff failed to monitor a behavioral health patient by failing to ensure constant observation was performed according to the physician orders for 1 of 2 patients (#9).
~ cross refer to 482.13 Patient Rights Condition: Tag A0144.

2. The hospital staff failed to provide a safe physical environment for a behavioral health patient on suicide precautions by failing to ensure hospital equipment with cords and sharps were not accessible for 1 0f 1 patients (#3).
~ cross refer to 482.13 Patient Rights Condition: Tag A0144.

3. The hospital nursing staff failed to have an effective nursing service providing oversight of ongoing operations to ensure the nursing staff supervised and evaluated patient care.
~ cross refer to 482.23 Nursing Services Condition: Tag A0395.

Based on hospital policy and procedure reviews, medical record reviews, observational tours, staff interviews, the hospital leadership failed to provide oversight and to have systems in place to ensure ensure monitoring of a behavioral health patient and failed to provide a safe physical environment according to the precaution level of a behavioral health patient.

The findings include:

1. The hospital staff failed to monitor a behavioral health patient by failing to ensure constant observation was performed according to the physician orders for 1 of 2 patients (#9).
~ cross refer to 482.13 Patient Rights Condition: Tag A0144.

2. The hospital staff failed to provide a safe physical environment for a behavioral health patient on suicide precautions by failing to ensure hospital equipment with cords and sharps were not accessible for 1 of 1 patients (#3).
~ cross refer to 482.13 Patient Rights Condition: Tag A0144.

Based on hospital policy and procedure reviews, medical record reviews, observational tours and staff interviews, the hospital Emergency Department (ED) staff failed to ensure observation was performed for 1 of 2 behavioral health patients on constant observation (patient #9).

The findings include:

Review of hospital policy, "Patient Observation/Precautions Guidelines" with a revision date of 01/2013 revealed, "POLICY: the safety of patients in a priority during hospitalization. The behavioral health inpatient services ensures the safety of the patients through a level of monitoring and observation matched to the acuity of their need. PURPOSE: ...PROCEDURE: A. Levels of observation and precautions on the inpatient Behavioral Health Unit include: 1. ...3. 1-1 observation (constant arm's length or constant visual observation)...L. 1-1 observation is defined as: 1. Constant observation within eyesight at all times or; 2. Within arms length at all times. ..."

Review of hospital policy, "Suicide/Homicide Screening and Precautions" with a revision date 10/2013 revealed, "POLICY: ...In the ED or an Inpatient unit (excluding Behavioral Health) family members are encouraged to stay with patients requiring Suicide/Homicide precautions. This does not negate (invalid) the need for 1:1 Precautions. ...PROCESS: I. Screening...II. Suicide/Homicide Precaution Orders A. ...C. Additional RN (Registered Nurse) responsibilities - Assign and Supervise: ...3. a. Remove all sharps from the room of a patient on Suicide/Precautions. Sharps include razors, scissors, knives, silverware, glass toiletries, nail clips and files, and any other object that can be used as a sharp weapon. b. ...Be aware of hospital equipment with cords as well...and electrical outlets. ..."

1. Open medical review conducted 03/18/2015 revealed Patient #9, a 13 year-old male presented to the hospital's ED on 03/16/2014 at 2141 in the custody of law enforcement while under IVC (Involuntary Commitment). Review of the IVC petition revealed "for several days", the patient's behavior had been "spiraling out of control." Further review revealed the patient had stabbed a fellow student with a plastic fork while at school, threaten to harm himself and prior to ED presentation, the patient fought police officers at a department store. Review of the IVC commitment findings revealed the patient was found to be mentally ill and dangerous to self or others. Review revealed at 2247, the patient was evaluated by the physician, received a diagnosis of violent behavior and anger outburst and had an order for psychiatric consultation. Review revealed the patient remained in the ED room #16 and was assigned a "Level II" (high risk) emergency presentation. Review of the ED physician's orders dated 03/17/2015 and 03/18/2015 revealed the patient was ordered behavioral and constant observation precautions. Review of the close observation forms documentation revealed from 03/16/2015 at 2330 to 03/18/2015 at 1730, the patient was monitored.

Observational tour conducted 03/18/2015 revealed from 1645 to 1655 (10 minutes), the patient was located in ED room 16. Observation revealed no health care personnel was located within arm's length nor within eyesight of the patient. Observation revealed the hospital ED staff failed to constantly observe a behavioral health patient as ordered by the physician.

Interview conducted 03/18/2015 at 1650 with nurse #1 revealed the nurse was unaware the patient was ordered 1:1 observation (constant observation). Interview revealed the nurse stated the patient was ordered every 15 minutes observations and they were performed as such. Interview revealed the ED staff failed to constantly observe the behavioral health patient according to the physician order.

Interview conducted 03/18/2015 at 1750 with Administrative Staff #2 revealed security guard #2 was observing the patient. Interview revealed the security officer #2 left the ED to take the other behavioral health patients to the fifth floor to take a shower. Interview revealed security officer #2 failed to inform the nursing staff prior to leaving the ED. Interview revealed the ED nursing staff was unable to provide the time security officer #2 left the ED. Interview revealed the hospital staff failed to constantly observe the behavioral health patient according to the physician.

Interview conducted 03/18/2015 at 1655 with the leadership team revealed the patient was ordered 1:1 observation and the patient was not constantly observed according to the physician order.


2. Observational tour conducted 03/17/2015 at 1030 revealed Patient #3 was located in ED room #15. Observation revealed nursing assistant #1 observed the patient from the room's entranceway. Observation of the room revealed an unsecured and patient accessible sharps container with sharps located on the inside, a computer with a movable non-breakaway arm, an overhead light with a movable non-breakaway arm and an unsecured television to prevent patient access.

Open medical record review conducted 03/18/2015 revealed Patient #3, a 30 year-old female presented to the hospital's ED on 03/16/2015 at 1905 by private vehicle. Review revealed the patient was triaged at 2303 and at 2315, the ED physician initiated an IVC petition related to eh patient hearing voices and the voices were telling her to kill herself and roommate. Review revealed the ED physician diagnosed the patient as homicidal (thoughts of killing others), suicidal (thoughts of self harm) and hallucinations (seeing things/hearing voices). Further review revealed the ED physician ordered a psychiatric consultation. Review of the IVC commitment findings revealed the patient was found to be mentally ill and dangerous to self or others.

Review revealed the patient location ED #15 and was assigned a "Level III" presentation (monitor). Review revealed on 03/17/2015 at 0110, The ED physician ordered suicide and constant observations. Review of the close observation forms documentation revealed from 03/16/2015 at 2330 to 03/17/2015 at 1500, the patient received suicide and 1:1 observation (constant observation). Review revealed at 0538, at 0842, at 1038 and at 1241, the patient continued to experience homicidal/suicidal hallucinations. Review revealed the ED physician's medication orders for the patient included: Ativan (anxiety) 1 milligram (mg) by mouth as needed; Haldol (antipsychotic) 5 mg by mouth as needed; and Clonazepam (sedative) 1 mg by mouth twice a day and Risperidone 2mg by mouth twice a day. Review of the Medication Administration Record (MAR) revealed the patient was administered the medications according to physician's orders. Review revealed the patient remained in ED #15 and was constantly observed. Review revealed on 03/17/2015 at 1500, the patient was transferred from the ED to Acute Hospital #2 for inpatient psychiatric care. Review revealed the transfer transportation was provided by the police department. Medical record review with observational tour revealed the hospital ED staff failed to provide a safe physical environment for a patient on suicide precautions.

Interview conducted on 03/18/2015 at 1655 with the hospital leadership team revealed ED room #15 was not a safe physical environment for a behavioral health patient on suicide precautions.

Based on hospital policy and procedure reviews, medical record reviews, observational tours, staff interviews, the hospital nursing staff failed to provide oversight and to have an effective nursing service providing oversight of ongoing operations to ensure the nursing staff supervised and evaluated patient care.

The findings include:

1. The hospital nursing staff failed to supervise and evaluate a behavioral health patient by failing to ensure constant observation was performed according to the physician orders for 1 of 2 patients (#9).
~ cross refer to 482.23(b)(30 Nursing Services Standard: Tag A0395.

2. The hospital nursing staff failed to provide a safe physical environment for a behavioral health patient on suicide precautions by failing to ensure hospital equipment with cords and sharps were not accessible for 1of 1 patients (#3).
~ cross refer to 482.23(b)(3) Nursing Services Standard: Tag A0395

Based on hospital policy and procedure reviews, medical record reviews, observational tours and staff interviews, the hospital Emergency Department (ED) staff failed to ensure observation was performed for 1 of 2 behavioral health patients on constant observation (patient #9).

The findings include:

Review of hospital policy, "Patient Observation/Precautions Guidelines" with a revision date of 01/2013 revealed, "POLICY: the safety of patients in a priority during hospitalization. The behavioral health inpatient services ensures the safety of the patients through a level of monitoring and observation matched to the acuity of their need. PURPOSE: ...PROCEDURE: A. Levels of observation and precautions on the inpatient Behavioral Health Unit include: 1. ...3. 1-1 observation (constant arm's length or constant visual observation)...L. 1-1 observation is defined as: 1. Constant observation within eyesight at all times or; 2. Within arms length at all times. ..."

Review of hospital policy, "Suicide/Homicide Screening and Precautions" with a revision date 10/2013 revealed, "POLICY: ...In the ED or an Inpatient unit (excluding Behavioral Health) family members are encouraged to stay with patients requiring Suicide/Homicide precautions. This does not negate (invalid) the need for 1:1 Precautions. ...PROCESS: I. Screening...II. Suicide/Homicide Precaution Orders A. ...C. Additional RN (Registered Nurse) responsibilities - Assign and Supervise: ...3. a. Remove all sharps from the room of a patient on Suicide/Precautions. Sharps include razors, scissors, knives, silverware, glass toiletries, nail clips and files, and any other object that can be used as a sharp weapon. b. ...Be aware of hospital equipment with cords as well...and electrical outlets. ..."

Open medical review conducted 03/18/2015 revealed Patient #9, a 13 year-old male presented to the hospital's ED on 03/16/2014 at 2141 in the custody of law enforcement while under IVC (Involuntary Commitment). Review of the IVC petition revealed "for several days", the patient's behavior had been "spiraling out of control." Further review revealed the patient had stabbed a fellow student with a plastic fork while at school, threaten to harm himself and prior to ED presentation, the patient fought police officers at a department store. Review of the IVC commitment findings revealed the patient was found to be mentally ill and dangerous to self or others. Review revealed at 2247, the patient was evaluated by the physician, received a diagnosis of violent behavior and anger outburst and had an order for psychiatric consultation. Review revealed the patient remained in the ED room #16 and was assigned a "Level II" (high risk) emergency presentation. Review of the ED physician's orders dated 03/17/2015 and 03/18/2015 revealed the patient was ordered behavioral and constant observation precautions. Review of the close observation forms documentation revealed from 03/16/2015 at 2330 to 03/18/2015 at 1730, the patient was monitored.

Observational tour conducted 03/18/2015 revealed from 1645 to 1655 (10 minutes), the patient was located in ED room 16. Observation revealed no health care personnel was located within arm's length nor within eyesight of the patient.

Interview conducted 03/18/2015 at 1650 with nurse #1 revealed the nurse was unaware the patient was ordered 1:1 observation (constant observation). Interview revealed the nurse stated the patient was ordered every 15 minutes observations and they were performed as such. Interview revealed the ED staff failed to constantly observe the behavioral health patient according to the physician order.

Interview conducted 03/18/2015 at 1750 with Administrative Staff #2 revealed security guard #2 was observing the patient. Interview revealed the security officer #2 left the ED to take the other behavioral health patients to the fifth floor to take a shower. Interview revealed security officer #2 failed to inform the nursing staff prior to leaving the ED. Interview revealed the ED nursing staff was unable to provide the time security officer #2 left the ED. Interview revealed the hospital staff failed to constantly observe the behavioral health patient according to the physician.

Interview conducted 03/18/2015 at 1655 with the leadership team revealed the patient was ordered 1:1 observation and the patient was not constantly observed according to the physician order.


2. Observational tour conducted 03/17/2015 at 1030 revealed Patient #3 was located in ED room #15. Observation revealed nursing assistant #1 observed the patient from the room's entranceway. Observation of the room revealed an unsecured and patient accessible sharps container with sharps located on the inside, a computer with a movable non-breakaway arm, an overhead light with a movable non-breakaway arm and an unsecured television to prevent patient access.

Open medical record review conducted 03/18/2015 revealed Patient #3, a 30 year-old female presented to the hospital's ED on 03/16/2015 at 1905 by private vehicle. Review revealed the patient was triaged at 2303 and at 2315, the ED physician initiated an IVC petition related to eh patient hearing voices and the voices were telling her to kill herself and roommate. Review revealed the ED physician diagnosed the patient as homicidal (thoughts of killing others), suicidal (thoughts of self harm) and hallucinations (seeing things/hearing voices). Further review revealed the ED physician ordered a psychiatric consultation. Review of the IVC commitment findings revealed the patient was found to be mentally ill and dangerous to self or others.

Review revealed the patient location ED #15 and was assigned a "Level III" presentation (monitor). Review revealed on 03/17/2015 at 0110, The ED physician ordered suicide and constant observations. Review of the close observation forms documentation revealed from 03/16/2015 at 2330 to 03/17/2015 at 1500, the patient received suicide and 1:1 observation (constant observation). Review revealed at 0538, at 0842, at 1038 and at 1241, the patient continued to experience homicidal/suicidal hallucinations. Review revealed the ED physician's medication orders for the patient included: Ativan (anxiety) 1 milligram (mg) by mouth as needed; Haldol (antipsychotic) 5 mg by mouth as needed; and Clonazepam (sedative) 1 mg by mouth twice a day and Risperidone 2mg by mouth twice a day. Review of the Medication Administration Record (MAR) revealed the patient was administered the medications according to physician's orders. Review revealed the patient remained in ED #15 and was constantly observed. Review revealed on 03/17/2015 at 1500, the patient was transferred from the ED to Acute Hospital #2 for inpatient psychiatric care. Review revealed the transfer transportation was provided by the police department. Medical record review with observational tour revealed the hospital ED staff failed to provide a safe physical environment for a patient on suicide precautions.

Interview conducted on 03/18/2015 at 1655 with the hospital leadership team revealed ED room #15 was not a safe physical environment for a behavioral health patient on suicide precautions.

Based on policy and procedure review, medical staff bylaws, medical record reviews, and staff interviews, the hospital staff failed to adhere to the medication documentation policy for 1 of 5 (patient #5) behavioral health patients in the Emergency Department (ED) and failed to establish authorship of medical record entries by the hospital staff performing constant observation for 1 of 5 behavioral health patients in the ED (patient #9).

The findings include:

Review of hospital policy, "Medication Administration And Documentation" with a revision date of 12/2013 revealed, "POLICY: It is the standard of care of ....Nursing documentation will be accurate and within guidelines governing nursing practice...Nursing staff will observe the six rights of medication administration: RIGHT PATIENT, RIGHT DRUG, RIGHT DOSE, RIGHT TIME/FREQUENCY OF ADMINISTRATION, AND DOCUMENTATION OF THE MEDICATION... PROCESS: IV. Documentation of Medication Administration: 1. Documentation of medication administration is to be done in the patient's electronic Medication Administration Record (eMAR) as the medication is administered... 14. Missed medication dose (for whatever reason) MUST be recorded on the eMAR by the assigned nurse and an explanation as to why the dose was not given in the Reason Code field of the eMAR. ...17. When a medication is discontinued, the initials, "DC" will appear in the Status Column of the eMAR and the order will drop to the bottom of the listed medications once it is documented against. If a nurse attempts to document against a discontinued order he/she is flagged that the order has been discontinued " ...

Review of the hospital Medical Staff Bylaws with a revision date of 05/12/2014 revealed, "....IV. MEDICAL RECORDS A. Contents of Medical Record...B. History and Physical...G. Signatures All clinical entries in the patient's medical record shall be accurately dated, times (timed), and authenticated, establishing authorship by written signature or identifiable initials. ...

1. Closed record review conducted on 03/19/15 revealed Patient #5, a 30 year-old female presented to the hospital ED on 02/15/15 at 1916 for "exhibiting strange behavior." Review revealed the patient had a history of animal cruelty and setting a building on fire. Review revealed the ED physician evaluated and diagnosed the patient as Post Traumatic Stress Disorder (PTSD), Oppositional Defiant Disorder (ODD), Antisocial Disorder, and Intellectual Developmental Delay (IDD). Review revealed the patient was assigned a "Priority III" presentation (two or more resources). Review revealed the ED physician ordered the patient a psychiatric consultation. Review revealed at 2112, the psychiatric consultation was completed and revealed "clinical impression" of Hypokalemia (low Potassium) and Mood Disorder.


Review of the ED physician orders revealed the following medication orders: "Clonazepam (antipsychotic) 1mg by mouth 0900, 1300, 2100 (dose frequency not indicated) on 2/15/2015 at 2215; Pantoprazole (Protonix-stomach acid) 40mg po daily on 2/16/15 at 1000; Ortho Tri-Cyclen Lo 0.18/0.215/0.25 1 tab daily (birth control-no route of administration indicated), and Prevident (mouth care) 5000 Plus 1 dose by mouth as directed." Review revealed Patient #5 was discharged to a resthome on 02/16/2015 at 1630. Review revealed the hospital ED nursing staff failed to adhere to the medication administration and documentation policy.

Interview with pharmacy staff on 03/19/15 at 1430 revealed it was the understanding that when medications were administered, it was indicated (documented) on the MAR as such. Interview revealed the hospital ED nursing staff failed to adhere to the medication administration and documentation policy.

Interview with Director of ED services and the Chief Nursing Officer (CNO) 3/19/15 at 1645 revealed the hospital does not have a separate policy to follow when using the paper MAR and follows guidelines outlined in D-50-C01 Medication Administration and Documentation. Interview revealed scheduled doses would be initialed, if administered and if not, "documentation for the missed dose would be expected." Interview revealed the hospital ED nursing staff failed to adhere to the medication administration and documentation policy.

2. Observational tour conducted 03/17/2015 at 1030 revealed Patient #9 was located in ED room 16. Observation revealed security officer #1 was sitting in a chair and performing constant observations. Observation revealed nursing assistant #1 documented the observed behavior according to security officer #1 observation. Observation revealed the hospital staff failed to establish authorship of medical record entries.

Open medical review conducted 03/18/2015 revealed Patient #9, a 13 year-old male presented to the hospital's ED on 03/16/2014 at 2141 in the custody of law enforcement while under IVC (Involuntary Commitment). Review of the IVC petition revealed "for several days", the patient's behavior had been "spiraling out of control." Further review revealed the patient had stabbed a fellow student with a plastic fork while at school, threaten to harm himself and prior to ED presentation, the patient fought police officers at a department store. Review of the IVC commitment findings revealed the patient was found to be mentally ill and dangerous to self or others. Review revealed at 2247, the patient was evaluated by the physician, received a diagnosis of violent behavior/anger outburst and had an order for psychiatric consultation. Review revealed the patient remained in the ED room #16 and was assigned a "Level II" (high risk) emergency presentation. Review of the ED physician's orders dated 03/17/2015 and 03/18/2015 revealed the patient was ordered behavioral and constant observation precautions. Review of the close observation forms documentation revealed from 03/16/2015 at 2330 to 03/18/2015 at 1730, the patient was monitored. Review of the close observation form date 03/17/2015 from 0700 to 1900 revealed security officer #1 signature was not authenticated.

Observational tour conducted 03/17/2015 at 1030 revealed Patient #9 was located in ED room 16. Observation revealed security officer #1-non-clinical staff was sitting in a chair and performing constant observations. Observation revealed nursing assistant #1-clinical staff documented the observed behavior as by security officer #1 observation.

Interview conducted 03/17/2015 at 1110 with security officer #1 revealed the security officer made and reported the observation to nursing assistant #1 to document. Interview revealed nursing assistant #1 was not the author of the observational monitoring.

Based on policy and procedure review, Crash Cart Maintenance Flowsheet (CCMF) review, observation, and staff interviews, the hospital failed to ensure equipment was maintained at an acceptable level of safety and quality for 4 of 4 crash carts on Unit 2 Medical/Surgical/Peds, Unit 4 Surgical floors, and Emergency Department.

The findings include:

1. Review of hospital policy, "Crash Carts (Adult & Pediatric), with a revision date of 02/2014 revealed, "POLICY: Each Department ensures their Unit specific crash cart(s) is fully/stocked and operational via daily checks ... PROCEDURE: I. Crash carts are checked by appropriate departmental staff. Checks include: A. Ensuring the cart is locked; B. Ensuring that the numbered lock corresponds to the number documented; C. Defibrillators are checked for functioning and paper supply (unplug defibrillator, fire defibrillator, then re-plug; D. Ensuring E.T. (endotracheal) Box is sealed; E. Portable suction on side of cart will be checked for proper function, F. If locks not in place or equipment not functioning, obtain replacements; G. After completing above checks, the staff member performing will complete the crash cart log."

2. Review of hospital policy, "Nursing Non-Stock Materials Management" with a revision date of 02/2014 revealed, "POLICY: ...These items are not routinely stocked by every department and therefore the ordering unit is responsible for the appropriate management of those articles. ...PROCESS: 1. ...2. Departments who order non-stock products accept responsibility for monthly stock rotation and any expired supplies. ..."

3. Review of the March 2015 CCMF during tour of Unit 2 on 3/18/2015 at 1140 revealed, 2 of 17 days (3 and 4) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33 on the "Adult" CCMF and 8 of 17 days (1, 3, 4, 6, 7, 10, 11, and 16) on the "Peds" CCMF. Review of the February 2015 CCMF on Unit 2 revealed, 11 of 28 days (6, 7, 8, 10, 11, 13, 17, 18, 25, 26, and 27) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33 on the "Adult" CCMF and 10 of 28 days (5, 6, 8, 10, 11, 13, 17, 18, 26, and 27) on the "Peds" CCMF. Review of the January 2015 CCMF of Unit 2 revealed, 5 of 31 days (10, 13, 26, 27, and 29) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33 on the "Adult" CCMF and 6 of 31 days (7, 12, 13, 26, 27, and 30) on the "Peds" CCMF.

Review of the March 2015 CCMF during observation of Unit 4 on 3/18/2015 at 1425 revealed, 3 of 17 days (2, 8, and 10) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33. Review of the February 2015 CCMF revealed 1 of 28 days (5) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33. Lastly, review of the January 2015 CCMF revealed 1 of 31 days (10) did not have elements of documentation outlined in A.-G. of hospital policy, D-50-A33.

Interview with unit 2 Director of Medical Services (DMS) 3/18/2015 at 1145 revealed, the unit experiences "no issues with logs (CCMF) routinely" and documentation of same are on the "list of improvements as a quality initiative now that I'm here". Interview revealed missing documentation "seems to be a weekend thing" and "charge nurses are now responsible for ensuring completion of checks". Interview revealed the DMS will be "performing inspections on a routine basis" going forward.

Staff interview with nursing staff on unit 2, Medical/Surgical/Peds 3/18/2015 at 1210 revealed, "We do forget sometimes but for the most part, we check them (crash carts) daily. Staff interview revealed having the carts in an area that is not readily visible makes it "a little harder to remember". Staff interview revealed "now that they (crash carts) are assigned, it will be better". Staff interview on unit 4 with the Director of Medical Services on 3/18/2015 at 1445 revealed checking crash carts and completion of the CCMF is an assigned duty of the charge nurse and "the process works well" for them.

Interview conducted 03/18/2015 at 1840 with Leadership revealed the hospital staff could not provide the December 2014 CCMF for unit 2 Medical/Surgical/Peds "Adult" and "Peds", related to they were "unable to find them".

2. Observational tour of the Radiology Department conducted 03/17/2015 at 1130 revealed Computed Tomography (CT) Scanner #2. Observation of the non-stock supplies revealed two (2)-10 milliliter (ml) unopend multi dose vials of Lidocaine with a date of 10/2014 and 2-10 ml unopend single dose vials of Sterile water with a date of 01/2015.

Interview conducted 03/17/2015 at 1130 with Radiology Technician #1 revealed this staff member monitor for expired supplies. Interview revealed the Lidocaine and Sterile water vials were out of date.